HIV and COVID-19: Intersecting Epidemics With Many Unknowns

Catherine R. Lesko; Angela M. Bengtson


Am J Epidemiol. 2021;190(1):10-16. 

In This Article

Substance Use/Mental Health Comorbidities

PLWH have a high prevalence of alcohol use, other drug use, and mental health disorders that might present unique risks and challenges during the SARS-CoV-2 pandemic. Physical distancing restrictions and related depression and anxiety might lead to increased alcohol and other drug use. Epidemiologists should consider novel data sources to track some of these trends. For example, Nielsen Retail Measurement Services reports dramatic increases (+234%) in online alcohol sales and sales of larger volumes of alcohol.[40] We will continue to need to rely on more traditional surveys about alcohol and other drug use, however, to know whether individual PLWH are increasing their consumption (to go beyond ecological inference) and whether they are shifting where and how they use alcohol and other drugs. Even shifts in where and with whom alcohol and other drugs are consumed could have consequences for PLWH related to the venues and networks in which alcohol and drug use occurs, including sexual risk behaviors, sharing of needles or drug paraphernalia, and exposure to violence.[41] Finally, persons with alcohol use disorder or substance use disorder might be less likely or able to comply with physical distancing restrictions if they need to go outside their homes to access alcohol or other drugs or, critically, medication-assisted treatments (such as methadone or buprenorphine).

Poor baseline mental health is likely to be exacerbated by physical distancing restrictions.[42] PLWH, particularly older PLWH, are already at high risk of social isolation,[43,44] and social structures and creative outlets that have helped people cope in the past might be dismantled under physical distancing restrictions. Breaking with physical distancing policy to seek out these coping outlets might be associated with additional stress due to fears of SARS-CoV-2 exposure or stigma. Accurate estimates of the risk associated with such activities for PLWH are critical to help individuals weigh the risk and benefits of participating in them but are not currently available. People able to shelter in place in their homes might face additional stressors at home if they are alone in their home, if being at home imposes additional caregiving responsibilities, or if they live with someone who poses a physical or emotional threat.

For persons with diagnosed mental health disorders, physical distancing restrictions and the transition to telehealth might lead to difficulty receiving or fully engaging in behavioral treatments for those disorders. Indeed, while delivery of mental health counseling might be one of the medical services most amenable to delivery via video conferencing, it might also serve as a "canary in the coal mine" for emergent disparities due to access to technology and private, safe spaces to participate in counselling.[30,45] For example, one HIV clinic in Chicago, Illinois, reported that some patients who had been receiving mental health counseling prior to the institution of physical distancing measures temporarily discontinued services when they were offered via telehealth, but other patients engaged in telecounseling for the first time. Engagement in telecounseling was universal among patients with stable income and housing but entirely absent among patients who were unstably housed with no steady source of income; in lieu of telecounseling, the latter group of patients received peer counseling, which was more flexible with respect to the time and locations in which it could occur.[16] In addition to exacerbated mental health symptoms as a result of physical distancing, persons with severe mental health symptoms might be at higher risk for SARS-CoV-2 infection if their understanding of public health messaging is impaired or if they do not understand their risk and how to mitigate it.[46]